ASK THE EXPERTS
Myofascial pain management: diagnosis, treatment options and challenges Cesar Fernández-de-las-Peñas*: Cesar Fernández-
de-las-Peñas completed his Bachelor’s degree in Physical Therapy in 2000, in Spain. He obtained his first PhD degree in Biomedical Sciences in 2007, under the supervision of Dr Lars Arendt-Nielsen at the Sensory-Motor Interaction Center at the University of Aalborg (Denmark). In 2008, he obtained his second PhD degree in Preventive Medicine, under the supervision of Drs Pareja and Cuadrado in Spain. He is the Head of the Division of the Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine at Universidad Rey Juan Carlos, Spain. He is also the group leader of the Pain Research Group at the same University. The research activities of his group are concentrated on neurosciences and assessment and management of pain. He has been invited as a Speaker to give lectures in more than 50 international and worldwide meetings with their related published abstracts/proceedings. He has published 170 publications in Journal Citation Reports’ indexed journals, being the first author of approximately 100 in the top-ten journals of specialties such as Rehabilitation, Clinical Neurology, Pediatrics, Orthopedics, Sports Medicine or Anesthesiology. Most of his published articles concentrate on human pain research and the interaction between motor control and chronic pain. The most relevant topics of the articles are focused on neck pain, headache, carpal tunnel syndrome, lateral epicondylalgia, whiplash, breast cancer and neurophysiological effects of physical therapy. He has also published several chapters of textbooks and is the editor of five textbooks. What are the main causes of myofascial pain and how does this condition present itself (main symptoms)? QQ
I believe that myofascial pain is one of the most overlooked and ignored sources of acute and chronic pain, and at the same time, constitutes one of the most common causes of musculoskeletal pain. Myofascial pain is characterized by the presence of myofascial trigger points (TrPs). The activation of a TrP may result from different factors, for example, acute or sustained overload, repetitive muscle overuse, stress or other medical causes. In fact, muscle pain is commonly a primary dysfunction and is not necessarily secondary to other diagnoses. For instance, TrPs may occur in the
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absence of other medical issues; however, TrPs can also be comorbid with underlying medical conditions, for example, knee osteoarthritis or irritable bowel syndrome, and also injuries such as whiplash. Although different definitions of TrPs are currently used among different disciplines, the most commonly accepted definition maintains that “a TrP is a hyperirritable spot within a taut band of a skeletal muscle that is painful on compression, stretch and/ or contraction of the tissue which usually responds with a referred pain and/or sensation.” As well as referred pain, other associated symptoms may also be present: for example, numbness, coldness, stiffness, weakness, fatigue, motor dysfunction, dizziness and autonomic responses. If any
*Department of Physical Therapy, Occupational Therapy, Rehabilitation & Physical Medicine, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922, Alcorcón, Madrid, Spain; [email protected]
10.2217/PMT.11.88 © 2012 Future Medicine Ltd
Pain Manage. (2012) 2(2), 113–115
part of
ISSN 1758-1869
113
NEWS & VIEWS Ask the Experts feature elicited by the TrP reproduces the symptoms reported by the patient, the TrP is considered active. If not, the TrP should be considered latent. In your opinion, is it relatively straightforward for pain clinicians to diagnose myofascial pain? QQ
One of the big concerns for myofascial pain is its correct diagnosis. Competent TrP diagnosis requires adequate manual skills, training and clinical practice to develop a high degree of reliability in the examination. There are several signs and symptoms that may be used for TrP diagnosis: Presence of a palpable taut band in a
skeletal muscle when accessible to palpation; Presence of a hyperirritable spot in the
taut band; Palpable local twitch response on snap-
ping palpation (or needling) of the TrP; Presence of referred pain elicited by stim-
ulation or palpation of the hyperirritable spot; Muscle weakness; Pain during muscle contraction or
stretching; Jump sign.
In addition, there are several factors that may contribute to a correct diagnosis: proper identification of taut bands, experience of the examiner, proper positioning of the patient or the assessor, proper palpation technique, the amount of manual force exerted on the palpated point and the duration of force applied, and so on. Therefore, proper training of clinicians is clearly needed. Nevertheless, I should comment that recent studies have demonstrated the ability to visualize TrP taut bands by using magnetic resonance elastography and sonographic elastography, although future studies are needed to optimize these procedures for the clinical setting. Are there many treatment options available for patients with myofascial pain and what are the major QQ
114
Pain Manage. (2012) 2(2)
complications associated with treatment of this condition?
There are several intervention modalities, particularly nonpharmacological, aimed at eliminating myofascial TrPs: ultrasound, thermotherapy, laser therapy, electrotherapy, magnetic therapy, manual therapies and dry needling. Among these interventions, manual therapies and dry needling are the basic treatment options. There is scientific evidence supporting the use of most of these interventions; however, high-quality randomized trials are needed. In clinical practice, their effectiveness will depend on the patient’s features and the muscle, since in some cases, dry needling would be much more effective than manual therapies, whereas in others, it would be the opposite. It is important to analyze the clinical picture of the patient and the potential role of each intervention. In addition, it is important that clinicians not only treat the TrP, but also the perpetuating factors. There are no serious complications associated with TrP treatment techniques. In some cases, patients may feel a slight worsening of their symptoms (if the manual therapy was applied too strongly), but it should disappear within a few hours. Dry needling is also a relatively safe approach, if properly applied. In fact, safety guidelines in different countries are being developed for this purpose. Nevertheless, it is important to recognize that dry needling can induce some muscle soreness for 24–48 h after treatment. How important is it to obtain the correct balance of both pharmacological and nonpharmacological approaches to this condition? QQ
The main therapeutic arsenal is represented by nonpharmacological approaches; nevertheless, some patients can exhibit nutritional discrepancies related to the presence of myofascial pain, or other underlying medical conditions that are perpetuating muscle pain. In such cases, it is important that clinicians combine both pharmacological and nonpharmacological approaches. Finally, injections of local anesthetics or other substances may also be used for the management of myofascial pain.
future science group
Ask the Experts In your experience, is it difficult to distinguish between myofascial pain syndrome patients and fibromyalgia patients? If patients are suffering with both conditions, does this change the treatment approach drastically? QQ
The topic of myofascial pain and fibromyalgia syndrome (FMS) is currently under debate, and the answer is not easy. I believe that myofascial pain and FMS are clearly two different clinical entities, but that they interact. Myofascial pain is characterized by TrPs, and FMS is characterized by widespread pain, sleep disturbances, fatigue, tenderness, cognitive difficulties and other somatic complaints. It is clear that a patient with myofascial pain and TrPs should not be diagnosed as a patient with FMS. However, a patient with FMS can also exhibit TrPs, and may therefore be suffering from myofascial pain. In recent years, we have published some studies demonstrating the presence of active TrPs in women with FMS, and that the referred pain elicited by TrPs was able to reproduce pain symptoms in FMS. However, the presence of TrPs in FMS does not mean that myofascial pain causes FMS; this would be completely wrong. In my clinical practice, I believe that patients with FMS should receive a multimodal approach including pharmacological, psychological and physical interventions. Obviously, patients with FMS exhibiting TrPs that appear to be clinically relevant for their symptoms should have such TrPs properly treated. If not addressed, the management of these patients would not be effective. Can you describe any current research you are undertaking in the study of myofascial pain management? QQ
My research group has demonstrated the relevance of TrPs in several chronic pain conditions: for example, tension-type headache, migraine, shoulder pain, lateral epicondylalgia, neck pain, whiplash and breast cancer. We have also conducted
NEWS & VIEWS
some randomized controlled trials looking at the effectiveness of including TrP treatment for patients with, for example, plantar heel pain or shoulder pain. In recent years, there has been an increasing interest in TrP pain. Several clinical and neurophysiological studies have been conducted and extremely important topics have been clarified. For instance, it is possible to visualize TrP with some imaging techniques, which is extremely helpful for research. Several clinical studies have demonstrated the relevance of TrP-referred pain in several chronic pain conditions. Furthermore, research from my friends Drs Hong-You Ge and Lars Arendt-Nielsen in Denmark has demonstrated the importance of latent TrPs. I believe that, in the words of the late Dr Simons: “the TrP virus has emerged in the last years.” Can you identify any areas in the field of myofascial pain management that require further research? QQ
I think that current research should focus on different directions: To determine the effectiveness of TrP therapy in several chronic pain conditions; To clarify the clinical and research diag-
nostic criteria for proper diagnosis of myofascial pain; To investigate the role of myofascial pain
in sensitization mechanisms in chronic musculoskeletal pain. Financial & competing interests disclosure C Fernández-de-las-Peñas has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
The editorial team is eager to receive any comments our readers might have on this topic for potential publication in future issues. Please direct any such communications to: Roshaine Gunawardana, Editor, Pain Management [email protected]
future science group
www.futuremedicine.com
115
Myofascial pain management: diagnosis, treatment options and challenges Cesar Fernández-de-las-Peñas*: Cesar Fernández-
de-las-Peñas completed his Bachelor’s degree in Physical Therapy in 2000, in Spain. He obtained his first PhD degree in Biomedical Sciences in 2007, under the supervision of Dr Lars Arendt-Nielsen at the Sensory-Motor Interaction Center at the University of Aalborg (Denmark). In 2008, he obtained his second PhD degree in Preventive Medicine, under the supervision of Drs Pareja and Cuadrado in Spain. He is the Head of the Division of the Department of Physical Therapy, Occupational Therapy, Rehabilitation and Physical Medicine at Universidad Rey Juan Carlos, Spain. He is also the group leader of the Pain Research Group at the same University. The research activities of his group are concentrated on neurosciences and assessment and management of pain. He has been invited as a Speaker to give lectures in more than 50 international and worldwide meetings with their related published abstracts/proceedings. He has published 170 publications in Journal Citation Reports’ indexed journals, being the first author of approximately 100 in the top-ten journals of specialties such as Rehabilitation, Clinical Neurology, Pediatrics, Orthopedics, Sports Medicine or Anesthesiology. Most of his published articles concentrate on human pain research and the interaction between motor control and chronic pain. The most relevant topics of the articles are focused on neck pain, headache, carpal tunnel syndrome, lateral epicondylalgia, whiplash, breast cancer and neurophysiological effects of physical therapy. He has also published several chapters of textbooks and is the editor of five textbooks. What are the main causes of myofascial pain and how does this condition present itself (main symptoms)? QQ
I believe that myofascial pain is one of the most overlooked and ignored sources of acute and chronic pain, and at the same time, constitutes one of the most common causes of musculoskeletal pain. Myofascial pain is characterized by the presence of myofascial trigger points (TrPs). The activation of a TrP may result from different factors, for example, acute or sustained overload, repetitive muscle overuse, stress or other medical causes. In fact, muscle pain is commonly a primary dysfunction and is not necessarily secondary to other diagnoses. For instance, TrPs may occur in the
News & Views News Journal Watch Ask the Experts Interview
absence of other medical issues; however, TrPs can also be comorbid with underlying medical conditions, for example, knee osteoarthritis or irritable bowel syndrome, and also injuries such as whiplash. Although different definitions of TrPs are currently used among different disciplines, the most commonly accepted definition maintains that “a TrP is a hyperirritable spot within a taut band of a skeletal muscle that is painful on compression, stretch and/ or contraction of the tissue which usually responds with a referred pain and/or sensation.” As well as referred pain, other associated symptoms may also be present: for example, numbness, coldness, stiffness, weakness, fatigue, motor dysfunction, dizziness and autonomic responses. If any
*Department of Physical Therapy, Occupational Therapy, Rehabilitation & Physical Medicine, Universidad Rey Juan Carlos, Avenida de Atenas s/n, 28922, Alcorcón, Madrid, Spain; [email protected]
10.2217/PMT.11.88 © 2012 Future Medicine Ltd
Pain Manage. (2012) 2(2), 113–115
part of
ISSN 1758-1869
113
NEWS & VIEWS Ask the Experts feature elicited by the TrP reproduces the symptoms reported by the patient, the TrP is considered active. If not, the TrP should be considered latent. In your opinion, is it relatively straightforward for pain clinicians to diagnose myofascial pain? QQ
One of the big concerns for myofascial pain is its correct diagnosis. Competent TrP diagnosis requires adequate manual skills, training and clinical practice to develop a high degree of reliability in the examination. There are several signs and symptoms that may be used for TrP diagnosis: Presence of a palpable taut band in a
skeletal muscle when accessible to palpation; Presence of a hyperirritable spot in the
taut band; Palpable local twitch response on snap-
ping palpation (or needling) of the TrP; Presence of referred pain elicited by stim-
ulation or palpation of the hyperirritable spot; Muscle weakness; Pain during muscle contraction or
stretching; Jump sign.
In addition, there are several factors that may contribute to a correct diagnosis: proper identification of taut bands, experience of the examiner, proper positioning of the patient or the assessor, proper palpation technique, the amount of manual force exerted on the palpated point and the duration of force applied, and so on. Therefore, proper training of clinicians is clearly needed. Nevertheless, I should comment that recent studies have demonstrated the ability to visualize TrP taut bands by using magnetic resonance elastography and sonographic elastography, although future studies are needed to optimize these procedures for the clinical setting. Are there many treatment options available for patients with myofascial pain and what are the major QQ
114
Pain Manage. (2012) 2(2)
complications associated with treatment of this condition?
There are several intervention modalities, particularly nonpharmacological, aimed at eliminating myofascial TrPs: ultrasound, thermotherapy, laser therapy, electrotherapy, magnetic therapy, manual therapies and dry needling. Among these interventions, manual therapies and dry needling are the basic treatment options. There is scientific evidence supporting the use of most of these interventions; however, high-quality randomized trials are needed. In clinical practice, their effectiveness will depend on the patient’s features and the muscle, since in some cases, dry needling would be much more effective than manual therapies, whereas in others, it would be the opposite. It is important to analyze the clinical picture of the patient and the potential role of each intervention. In addition, it is important that clinicians not only treat the TrP, but also the perpetuating factors. There are no serious complications associated with TrP treatment techniques. In some cases, patients may feel a slight worsening of their symptoms (if the manual therapy was applied too strongly), but it should disappear within a few hours. Dry needling is also a relatively safe approach, if properly applied. In fact, safety guidelines in different countries are being developed for this purpose. Nevertheless, it is important to recognize that dry needling can induce some muscle soreness for 24–48 h after treatment. How important is it to obtain the correct balance of both pharmacological and nonpharmacological approaches to this condition? QQ
The main therapeutic arsenal is represented by nonpharmacological approaches; nevertheless, some patients can exhibit nutritional discrepancies related to the presence of myofascial pain, or other underlying medical conditions that are perpetuating muscle pain. In such cases, it is important that clinicians combine both pharmacological and nonpharmacological approaches. Finally, injections of local anesthetics or other substances may also be used for the management of myofascial pain.
future science group
Ask the Experts In your experience, is it difficult to distinguish between myofascial pain syndrome patients and fibromyalgia patients? If patients are suffering with both conditions, does this change the treatment approach drastically? QQ
The topic of myofascial pain and fibromyalgia syndrome (FMS) is currently under debate, and the answer is not easy. I believe that myofascial pain and FMS are clearly two different clinical entities, but that they interact. Myofascial pain is characterized by TrPs, and FMS is characterized by widespread pain, sleep disturbances, fatigue, tenderness, cognitive difficulties and other somatic complaints. It is clear that a patient with myofascial pain and TrPs should not be diagnosed as a patient with FMS. However, a patient with FMS can also exhibit TrPs, and may therefore be suffering from myofascial pain. In recent years, we have published some studies demonstrating the presence of active TrPs in women with FMS, and that the referred pain elicited by TrPs was able to reproduce pain symptoms in FMS. However, the presence of TrPs in FMS does not mean that myofascial pain causes FMS; this would be completely wrong. In my clinical practice, I believe that patients with FMS should receive a multimodal approach including pharmacological, psychological and physical interventions. Obviously, patients with FMS exhibiting TrPs that appear to be clinically relevant for their symptoms should have such TrPs properly treated. If not addressed, the management of these patients would not be effective. Can you describe any current research you are undertaking in the study of myofascial pain management? QQ
My research group has demonstrated the relevance of TrPs in several chronic pain conditions: for example, tension-type headache, migraine, shoulder pain, lateral epicondylalgia, neck pain, whiplash and breast cancer. We have also conducted
NEWS & VIEWS
some randomized controlled trials looking at the effectiveness of including TrP treatment for patients with, for example, plantar heel pain or shoulder pain. In recent years, there has been an increasing interest in TrP pain. Several clinical and neurophysiological studies have been conducted and extremely important topics have been clarified. For instance, it is possible to visualize TrP with some imaging techniques, which is extremely helpful for research. Several clinical studies have demonstrated the relevance of TrP-referred pain in several chronic pain conditions. Furthermore, research from my friends Drs Hong-You Ge and Lars Arendt-Nielsen in Denmark has demonstrated the importance of latent TrPs. I believe that, in the words of the late Dr Simons: “the TrP virus has emerged in the last years.” Can you identify any areas in the field of myofascial pain management that require further research? QQ
I think that current research should focus on different directions: To determine the effectiveness of TrP therapy in several chronic pain conditions; To clarify the clinical and research diag-
nostic criteria for proper diagnosis of myofascial pain; To investigate the role of myofascial pain
in sensitization mechanisms in chronic musculoskeletal pain. Financial & competing interests disclosure C Fernández-de-las-Peñas has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript.
The editorial team is eager to receive any comments our readers might have on this topic for potential publication in future issues. Please direct any such communications to: Roshaine Gunawardana, Editor, Pain Management [email protected]
future science group
www.futuremedicine.com
115
